Reducing emergency admissions

Emergency admissions cost the NHS £13.7 billion in 2015-16 and pose a serious challenge to both the service and financial position of the NHS, according to today’s report by the National Audit Office (NAO). Over the last four years, the NHS has done well to manage the impact on hospitals, despite admitting more people as emergency admissions. While progress has been made in some areas the challenge of managing emergency admissions is far from being under control.

Overall emergency admissions grew by 24% from 2007-08 to 2016-17. In 2016-17, there were 5.8 million emergency admissions of which 24% were considered avoidable by NHS England.

While more people are being admitted, the time they spend in hospital is getting shorter. Most (79%) of the growth in emergency admissions from 2013-14 to 2016-17 was caused by people who did not stay in hospital overnight.

The rise in emergency admissions of people aged 65 and over was 12% in the past four years. Demographic changes explain only just over half this rise, which the Department is aware of and is doing further work to better understand the other drivers.

The number of bed days as a result of people being admitted through emergency admissions has increased from 32.41 million in 2013-14 to 33.59 million in 2016-17. This is an increase of 3.6%, which is less than the 9.3% increase in emergency admissions during the same period.

The NAO estimates that the real terms cost of emergency admissions has increased by 2.2% since 2013-14, from £13.4 billion to £13.7 billion in 2015-16, while emergency admissions increased by 7% over the same period.

NHS England and partners have developed a number of national programmes that aim to reduce the impact of emergency admissions. While the rate of growth in emergency admissions has slowed slightly in 2016-17, there is limited evidence to show that initiatives such as the Better Care Fund and the urgent and emergency care programme have brought about that slow down.

Significant challenges do remain in managing emergency admissions:

Bed closures have increased the pressures posed on acute hospitals by rising emergency admissions. From 2010-11 to 2016-17, the average number of available general and acute beds has fallen by 6,268 beds (5.8%). Bed occupancy has been increasing since at least 2010-11, reaching a seasonal peak of 91.4% in the fourth quarter of 2016-17.

Using data from 72 Trusts, Healthwatch England has estimated emergency readmissions to have risen by 22.8% between 2012-13 and 2016-17. Over the same period we calculate overall emergency admissions rose by 10.2%. While there are some issues about the reliability and consistency of the data reported by Healthwatch, the rate of growth raises questions about the appropriateness of some decisions to discharge and/or the support provided to help people recuperate.

Capacity in the community to prevent emergency admissions does not currently meet demand. As of October 2017, there was not a clear plan for how the £10 billion the Department of Health & Social Care estimates was spent on community health care could be better used to manage demand. Since then NHS England has set up a project to develop community services to support the Five Year Forward View.

NHS England does not have good enough data on emergency admissions as the available hospital data does not always accurately record the causes, severity, source of referral and diagnosis of patients. According to an assessment by the Royal College of Emergency Medicine and NHS Digital, NHS England only has records on where people come from for 5% of attendances, for example, a road traffic accident. In response, from October 2017, NHS England has required emergency departments to collect more comprehensive data.

In 2016-17, the number of emergency admissions across England varied between 73 and 155 admissions per 1,000 GP weighted population. The Department and NHS England do not fully understand the reasons for these considerable local variations so cannot identify the extent to which they are caused by local health and social care practices which lead to better management of emergency admissions, or other factors.

The NAO recommends that the Department and NHS England should establish an evidence base for what works in reducing emergency admissions and use this to inform future national programmes. They should also link hospital activity data with primary, community health care and social care data to enable health and social care practitioners so they can make the most informed decision about whether a patient requires emergency hospital treatment.

“It is a problem for all of us that A&Es remain overloaded and a constant point of stress for patients and the NHS. A lot of effort is being made by NHS England. At the centre of this is increased ‘daycase’ treatment but the decision to stop methodical measurement of emergency readmissions a few years ago makes it difficult to understand whether daycase interventions achieve enduring results.”

Amyas Morse, head of the National Audit Office

Notes for Editors

£13.7bn

cost of emergency admissions 2015-16

5.8 million

emergency admissions in 2016-17

2.1%

increase in emergency admissions between 2015-16 and 2016-17

79%

of the increase in emergency admissions between 2013-14 and 2016-17 was caused by people who did not stay overnight.

65%

proportion of hospital emergency bed days occupied by patients aged 65 and over in 2016-17.

53%

of growth in emergency admissions came from people aged 65 and over between 2013-14 and 2016-17

27%

increase in people being admitted and not staying overnight from 2013-14 to 2016-17.

32%

of local areas reporting they had reduced emergency admissions by the target they set in their Better Care Fund plans for 2016-17.

NHS England defines an emergency admission to be ‘when admission is unpredictable and at short notice because of clinical need’. Some emergency admissions are clinically appropriate and unavoidable. Others could be avoided by providing alternative forms of urgent care, or by providing appropriate care and support earlier to prevent a person becoming unwell enough to require an emergency admission.

A large proportion of the growth in emergency admissions (79%) from 2013-14 to 2016-17 was accounted for by people who did not stay in hospital overnight. There has been a 27% increase in people being admitted and not staying overnight from 2013-14 to 2016-17. In overall terms, nearly half of emergency admissions in 2016-17, resulted in people staying for two or more nights, and nearly one-third did not stay overnight.

Bed occupancy increased, reaching a seasonal peak in 91.4% in the fourth quarter of 2016-17. This above 85% – the level at which previous NAO work has found that hospitals can expect to have regular bed shortages, periodic bed crises, and increased numbers of hospital‑acquired infections.

A “weighted population” uses NHS Digital’s needs-weighted population data to strip out the impact of a local area’s demographics, health needs, and local costs on emergency admissions, and so gives a better picture of clinical commissioning group-level system performance.

Press notices and reports are available from the date of publication on the NAO website. Hard copies can be obtained by using the relevant links on our website.

The National Audit Office scrutinises public spending for Parliament and is independent of government. The Comptroller and Auditor General (C&AG), Sir Amyas Morse KCB, is an Officer of the House of Commons and leads the NAO. The C&AG certifies the accounts of all government departments and many other public sector bodies. He has statutory authority to examine and report to Parliament on whether departments and the bodies they fund, nationally and locally, have used their resources efficiently, effectively, and with economy. The C&AG does this through a range of outputs including value for money reports on matters of public interest; investigations to establish the underlying facts in circumstances where concerns have been raised by others or observed through our wider work; landscape reviews to aid transparency and good practice guides. Our work ensures that those responsible for the use of public money are held to account and helps government to improve public services, leading to audited savings of £734 million in 2016.

PN: 14/18

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